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® Waste Tire Sey & inspection Rep( Inspection Report Number <br /> State of <br /> 81'fornia <br /> (New 04/04) Survey Form - Page 1 I 1 - 1088075 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> u-irss <br /> Physical Address � 1 <br /> 419Z A. Aypo4 Dr. - <br /> Inspection Date 41 Z / 6 q <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> L � ' 53 0P QPM <br /> G L11 Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) -15 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ® Active ® Passenger & Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 77 <br /> HAULING AND MANIFEST REQUIREMENT- <br /> O Notice Of Violation Q Extensloq <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days V(Required for NOV or EXT) <br /> - --Q Q 14 CCR 18459.3-Retention of Comprehensive Trip Logs for 3 Years --- <br /> i <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities __ f <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 Other: <br /> Comments - <br /> lacit �eS �tf_ �I r C� <br /> 1Z &.cam� Inf-ItCS civ l;ee,T he ,�.7CJ7 � <br /> -'1e-Af LTL-5 Pl o vim C'Jl� _ho 7 c c� . <br /> dg - <br /> Inspection Form Included: Q o 6 <br /> Comments Included: Q <br /> usiness Rep's Signature Phone Number Inspect 's Sig t e Phone Number <br /> INSTRUCTIONS ON BACK ® JAIMIPILI62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />